Magnetic resonance imaging of plantar soft tissue structures of the tarsus and proximal metatarsus in foals and adult horses.

OBJECTIVES: The object of this study was to describe previously defined soft tissue structures by using spin and gradient sequences in a 0.5 Tesla magnetic resonance system in order to improve the characterisation of tendon and ligaments at the plantar region of the equine tarsus and metatarsus while considering possible age-related variations. METHODS: Cadaveric hindlimbs from twenty-two Warmblood horses with an age range from one month to twenty-five years were examined in spin and gradient echoes. The proximal suspensory ligament from six limbs was dissected to assign the signal intensities histologically. For statistical analysis, horses were divided into two groups (≤3 years and >3 years) for evaluating signal intensity and homogeneity of the plantar tendons and ligaments. RESULTS: Focal increase of the signal intensity within the deep digital flexor tendon was significantly more present in horses older than three years. Signal alterations of the long plantar ligament were seen without a significant dependency to age. The accessory ligament of the deep digital flexor tendon could not be visualized on all images within the region of interest. The morphology of the proximal suspensory ligament was not affected by age-related changes. CLINICAL RELEVANCE: Spin and gradient echoes in MRI were suitable to identify and assess soft tissue structures at the plantar aspect of the equine tarsus and proximal metatarsus. Age-related appearance must be considered when interpreting magnetic resonance images.

The proximal aspect of the suspensory ligament in the horse: How precise are ultrasonographic measurements?

REASONS FOR PERFORMING STUDY: To evaluate intra- and interobserver variability in ultrasonographic measurements of the proximal aspect of the suspensory ligament (PSL) in the horse. HYPOTHESIS: A minimum difference of ≥20% is required to differentiate reliably between physiological and pathological alterations related to dimensions. MATERIALS AND METHODS: Two operators examined the PSL in all 4 limbs of 14 horses twice using different techniques and different probes with and without standoff pads. Measurements were taken from the longitudinal and transverse images. Inter- and intraoperator variability was evaluated using agreement indices (AI) and the 95% limits of agreement (LOA). RESULTS: On the longitudinal scan the mean inter- and intraoperator AIs for dorsopalmar/-plantar thickness were both ≥0.89 and the 95% LOA were within target values for almost all intra- and interoperator comparisons. Similar mean AIs and 95% LOA were calculated for the dorsopalmar/-plantar thickness on the transverse image. For lateromedial width, cross-sectional area and circumference on the transverse scan, the mean inter- and intraoperator AIs ranged between 0.81 and 0.95 and the 95% LOA were higher than target values regardless of the imaging technique used. In general, better values for AIs and 95% LOA were achieved in the fore- compared with the hindlimb. CONCLUSION AND CLINICAL RELEVANCE: Acceptable precision was identified within and between operators only for the dorsopalmar/-plantar thickness in longitudinal and in transverse scanning directions. For the lateromedial width, cross-sectional area and circumference, a relatively large variability was identified. This aspect has to be considered if these parameters are to be used for objective measurement of the PSL from the transverse ultrasound image.

Comparison of tenoscopic and ultrasonographic methods of examination of the digital flexor tendon sheath in horses.

The purpose of this study was to compare sonographic and tenoscopic findings with the purpose of establishing the accuracy and limitations of ultrasonograophy as a non-invasive diagnostic modality in evaluating the DFTS and its enclosed tendons. The medical records from 22 horses which underwent tenoscopic desmotomy of the palmar/plantar annular ligament were evaluated in a retrospective study. The qualitative assessment of sonogrophic and tenoscopic findings were documented for the digital flexor tendon sheath (DFTS), the palmar/plantar annular ligament (PAL), the superficial digital flexor tendon (SDFT) and the deep digital flexor tendon (DDFT). The abnormalities diagnosed sonographically within the DFTS were verifiable tenoscopically with a sensitivity of 90.9% and a specificity of 53.8%. The positive predictive value of sonographic examination at the DFTS was 62.5%. The sensitivity of the sonographic examination at the PAL was 68.8%, the specificity was 50% and the positive predictive value 73.3%. Sonographic examination of the SDF tendons revealed abnormal findings in 12 tendons. The tenoscopic examination confirmed these findings on six tendons when they had a pronounced fibrillated or rough tendon surface or tear on the border. Six superficial flexor tendons and seven deep digital flexor tendons had abnormalities seen tenoscopically which were not visible on sonographic examination. Sonographic examination located lesions of the DDFT in four limbs. On tenoscopic examination the lesions could be detected in seven other DDF tendons, including signs of inflammation at the tendon surface that were not seen ultrasonographically (sensitivity 36.4%). Recognition of the limitations of sonographic results should be kept in mind so as not to misinterpret findings, especially if echogenic materials are observed.

Ultrasonographic examination of the equine sacroiliac region.

REASONS FOR PERFORMING STUDY: Little information exists about the normal ultrasonographic appearance of the equine sacroiliac region, but knowledge of the ultrasonographic anatomy is necessary to understand the possible pathological changes in sacroiliac diseases. OBJECTIVES: The normal ultrasonographic appearance of soft tissues and bony structures of the sacroiliac region in horses was studied in order to establish clinically relevant reference parameters. METHODS: Thirteen cadaver specimens were examined using a transcutaneous approach above the tubera sacrale to image the dorsal sacroiliac ligament and the tendon of the longissimus dorsi muscle. A rectal approach was used to outline the sacroiliac joint and its adjacent structures. Thirteen sound horses with no history of back pain were examined following the same protocol as for the post mortem examinations. RESULTS: The tendon of the longissimus dorsi muscle can clearly be distinguished from the dorsal sacroiliac ligament, especially in longitudinal images. Transrectal examination of the sacroiliac joint consists of evaluation of the bony surfaces of the sacrum and ilium in comparison with the contralateral side. CONCLUSIONS: Ultrasonographic examination of the sacroiliac region provided clear images of the caudomedial border of the sacroiliac joint and its adjacent structures and is a useful aid in the diagnosis of sacroiliac joint diseases and adjacent lesions. The study has shown ultrasonography to be a useful method for examining and differentiating the longissimus dorsi muscle and the dorsal sacroiliac ligament at the level of the tubera sacrale. POTENTIAL RELEVANCE: Diagnostic ultrasound is available to most practitioners. These reference ultrasound parameters may help to improve the diagnosis of sacroiliac diseases.

Sleep in the laboratory and sleep at home II: comparisons of middle-aged insomnia sufferers and normal sleepers.

STUDY OBJECTIVES: The study compared adaptation responses and sleep pattern differences shown by normal sleepers and insomnia sufferers during lab (LPSG) and home (HPSG) polysomnography. DESIGN: A counter-balanced, matched-group design was used. Participants underwent 3 consecutive nocturnal LPSG's and 3 consecutive nocturnal PSG's in their homes (HPSG's). SETTING: The sleep disorders laboratories at affiliated VA and university medical centers. PARTICIPANTS: Thirty-five (18 women) middle-aged (40 to 59 years) noncomplaining normal sleepers and an age-matched sample of 33 (17 women) individuals who met structured interview criteria for persistent primary insomnia were the study participants. MEASUREMENTS AND RESULTS: A series of multivariate and univariate analyses were conducted with 9 common sleep parameters to address study objectives. Bed partner influences were controlled by conducting separate sets of analyses for those with and without routine home bed partners. The interaction of participant type (normal vs. insomnia), sleep setting, and PSG sequence (HPSG 1st vs. LPSG 1st) affected first night values of sleep efficiency and stage 2 sleep among those without routine bed partners, and REM latency and sleep efficiency among those with routine bed partners. Analyses which controlled for first night and sequencing effects showed a significant participant type x sleep setting interaction among those with bed partners. These latter analyses suggested that LPSG's may underestimate the home sleep time of insomnia sufferers and overestimate the sleep continuity of normal sleepers, at least among those who routinely sleep with a bed partner. CONCLUSIONS: The nocturnal recording site may influence adaptation effects and sleep pattern differences noted between insomnia sufferers and normal sleepers.

Does cognitive-behavioral insomnia therapy alter dysfunctional beliefs about sleep?

STUDY OBJECTIVES: This study was conducted to exam the degree to which cognitive-behavioral insomnia therapy (CBT) reduces dysfunctional beliefs about sleep and to determine if such cognitive changes correlate with sleep improvements. DESIGN: The study used a double-blind, placebo-controlled design in which participants were randomized to CBT, progressive muscle relaxation training or a sham behavioral intervention. Each treatment was provided in 6 weekly, 30-60-minute individual therapy sessions. SETTING: The sleep disorders center of a large university medical center. PARTICIPANTS: Seventy-five individuals (ages 40 to 80 years of age) who met strict criteria for persistent primary sleep-maintenance insomnia were enrolled in this trial. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: Participants completed the Dysfunctional Beliefs and Attitudes About Sleep (DBAS) Scale, as well as other assessment procedures before treatment, shortly after treatment, and at a six-month follow-up. Items composing a factor-analytically derived DBAS short form (DBAS-SF) were then used to compare treatment groups across time points. Results showed CBT produced larger changes on the DBAS-SF than did the other treatments, and these changes endured through the follow-up period. Moreover, these cognitive changes were correlated with improvements noted on both objective and subjective measures of insomnia symptoms, particularly within the CBT group. CONCLUSIONS: CBT is effective for reducing dysfunctional beliefs about sleep and such changes are associated with other positive outcomes in insomnia treatment.

Effects of enrofloxacin and ciprofloxacin hydrochloride on canine and equine chondrocytes in culture.

OBJECTIVE: To study chondrotoxic effects of enrofloxacin (ENR) and ciprofloxacin hydrochloride (CFX) on canine and equine articular chondrocytes in culture and to compare the effects with that of cultivation in Mg2+-free medium. SAMPLE POPULATION: Chondrocytes from articular cartilage of 4- and 6 -month old dogs and 2- to 4- year-old horses. PROCEDURE: Chondrocytes were cultivated with 10, 40, 80, and 160 microg of CFX/ml, 10, 50, 100, and 150 microg of ENR/ml, or in Mg2+-free medium. A live-to-dead test was performed to test cytotoxic effects. Morphologic changes were evaluated by electron microscopy. An attachment assay was used to test the ability of chondrocytes to adhere to collagen type-II coated-chamber slides in the presence of CFX and with Mg2+-free medium. RESULTS: Chondrocytes cultivated in quinolone-supplemented medium or Mg2+-free medium had a decreased ability to adhere to culture dishes. Cell shape and the actin and vimentin cytoskeleton changed in a concentration-dependent manner. These effects were not species-specific and developed with both quinolones. On day 1 of culture, adhesion of chondrocytes to collagen type II was reduced to 70 and 45% of control values in the CFX treatment and Mg2+-free treatment groups, respectively. On day 5 of culture, adhesion of chondrocytes was reduced to 45 and 40% of control values in the CFX treatment and Mg2+-free treatment groups, respectively. CONCLUSION AND CLINICAL RELEVANCE: In vitro, chondrotoxic effects of quinolones appear to be the result of irregular integrin signaling and subsequent cellular changes. Drug concentrations leading to morphologic changes in vitro may be achieved in articular cartilage in vivo.

Simulation of cooling-water discharges from power plants.

Accurate simulation of the temperature distribution in a cooling lake or reservoir is often required for feasibility studies of engineering options that increase the cooling capacity of the waterbody. A three-dimensional hydrodynamic and temperature model has been developed and applied to several cooling lakes in the south-eastern United States. In this paper, the details of the modeling system are presented, along with the application to the Flint Creek Lake.

Cognitive behavioral therapy for treatment of chronic primary insomnia: a randomized controlled trial.

CONTEXT: Use of nonpharmacological behavioral therapy has been suggested for treatment of chronic primary insomnia, but well-blinded, placebo-controlled trials demonstrating effective behavioral therapy for sleep-maintenance insomnia are lacking. OBJECTIVE: To test the efficacy of a hybrid cognitive behavioral therapy (CBT) compared with both a first-generation behavioral treatment and a placebo therapy for treating primary sleep-maintenance insomnia. DESIGN AND SETTING: Randomized, double-blind, placebo-controlled clinical trial conducted at a single academic medical center, with recruitment from January 1995 to July 1997. PATIENTS: Seventy-five adults (n = 35 women; mean age, 55.3 years) with chronic primary sleep-maintenance insomnia (mean duration of symptoms, 13.6 years). INTERVENTIONS: Patients were randomly assigned to receive CBT (sleep education, stimulus control, and time-in-bed restrictions; n = 25), progressive muscle relaxation training (RT; n = 25), or a quasi-desensitization (placebo) treatment (n = 25). Outpatient treatment lasted 6 weeks, with follow-up conducted at 6 months. MAIN OUTCOME MEASURES: Objective (polysomnography) and subjective (sleep log) measures of total sleep time, middle and terminal wake time after sleep onset (WASO), and sleep efficiency; questionnaire measures of global insomnia symptoms, sleep-related self-efficacy, and mood. RESULTS: Cognitive behavioral therapy produced larger improvements across the majority of outcome measures than did RT or placebo treatment. For example, sleep logs showed that CBT-treated patients achieved an average 54% reduction in their WASO whereas RT-treated and placebo-treated patients, respectively, achieved only 16% and 12% reductions in this measure. Recipients of CBT also showed a greater normalization of sleep and subjective symptoms than did the other groups with an average sleep time of more than 6 hours, middle WASO of 26.6 minutes, and sleep efficiency of 85.1%. In contrast, RT-treated patients continued to report a middle WASO of 43.3 minutes and sleep efficiency of 78.8%. CONCLUSIONS: Our results suggest that CBT represents a viable intervention for primary sleep-maintenance insomnia. This treatment leads to clinically significant sleep improvements within 6 weeks and these improvements appear to endure through 6 months of follow-up.

Psychometric comparisons of the standard and abbreviated DBAS-10 versions of the dysfunctional beliefs and attitudes about sleep questionnaire.

OBJECTIVE: To evaluate the psychometric properties of the DBAS-10, a recently proposed abbreviated version of the Dysfunctional Beliefs and Attitudes About Sleep Scale (DBAS). POPULATION: Two hundred and eleven (69 normal sleepers; 142 insomnia suffers) middle-aged and older adults (age 40-79 years) drawn from two separate cohorts of research volunteers. METHOD: Volunteers in the first cohort (69 normal sleepers; 69 insomnia sufferers) completed the full DBAS on one occasion. Volunteers in the second cohort (73 insomnia sufferers) completed the full DBAS prior to treatment and at multiple subsequent time points to assess treatment-related changes. A series of statistical tests were conducted with one or both cohorts to investigate the comparability of the DBAS-10 and full DBAS, the internal consistency of each instrument, the factor structure of the DBAS-10, and the validity of this instrument. RESULTS: Statistical findings showed that the DBAS-10 correlated highly with the full DBAS, had respectable internal consistency, effectively discriminated normal sleepers from insomnia sufferers, and detected cognitive changes resulting specifically from CBT intervention. Although factor analysis empirically identified three conceptually meaningful DBAS-10 subscales, the subscale structure varied somewhat from previous factor analytic findings with this instrument. CONCLUSIONS: The DBAS-10 generally appears to have very acceptable psychometric properties although subscales previously proposed for this instrument may vary across research populations. Nonetheless, results encourage the use of this instrument in studies concerned with the nature and treatment of sleep-disruptive cognitions.

Slow-wave sleep and waking cognitive performance II: Findings among middle-aged adults with and without insomnia complaints.

Previous studies showing a relationship between nocturnal slow-wave sleep (SWS) and subsequent diurnal performance among young normal sleepers and older insomnia sufferers have provided limited support for the notion that this sleep stage serves a restorative role for neurocognitive functioning. The current study, which examined the relationship between SWS and reaction time performance among middle-aged adults with and without insomnia complaints, was conducted to further explore this possibility. A sample of 31 noncomplaining middle-aged (ages 40 to 59 years) normal sleepers and a like-aged sample of 27 insomnia sufferers, provided data for the current investigation. All participants underwent nocturnal sleep monitoring immediately prior to undergoing a battery of daytime tests that measured simple reaction time, vigilance/signal detection, and complex reaction time. Results showed relationships between reaction time performances on some tasks and some SWS measures among both the normal sleepers and insomnia sufferers. Findings supported our prediction that the presence of sleep pathology (e.g., insomnia) alters the SWS-performance relationship observed, but the results failed to show a consistent relationship between SWS and subsequent performance within either sample. The findings suggest that the specific performance demands of the task in question as well as physiological parameters other than SWS may determine performance as well. Findings for this and previous studies do provide some support for the contention that the neurocognitive restorative value of SWS may change across the lifespan. Possible implications of the study's findings are discussed and directions for future research are considered.

Insomnia and the eye of the beholder: are there clinical markers of objective sleep disturbances among adults with and without insomnia complaints?

Previous findings suggest that some who report insomnia sleep well, whereas some noncomplaining individuals sleep rather poorly. This study was conducted to determine if mood, anxiety, and sleep-related beliefs might relate to perceived sleep disturbance. Thirty-two women and 32 men (aged 40-79 years) with primary insomnia and an aged-matched sample of 61 normal sleepers (31 women, 30 men) completed 6 nocturnal sleep recordings, as well as the Beck Depression Inventory (BDI), the Trait portion of the State-Trait Anxiety Inventory (STAI-2), and the Dysfunctional Beliefs and Attitudes About Sleep Questionnaire. Sleep and interview data were used to subdivide the majority of the sample (n = 108) into objective normal sleepers and subjective insomnia sufferers who seemingly slept well and subjective normal sleepers and objective insomnia sufferers who slept poorly. The 2 subjective subgroups showed the most marked differences on most of the psychometric measures. The findings suggest that the psychological factors scrutinized in this study may mediate sleep satisfaction and/or predict objective sleep difficulties.

Sleep disorders in older people.

Sleep complaints are common among older people. As there are often multiple contributing factors, insomnia should be considered a symptom, and not a diagnosis. There is a high prevalence of sleep apnea and nocturnal myoclonus. When these primary sleep disorders are suspected, the patient should be referred for polysomnography. Use of hypnotics should be discouraged for chronic insomnia. More research is needed to clarify the role of light therapy and melatonin in the treatment of sleep disorders in older people.

Slow-wave sleep and waking cognitive performance among older adults with and without insomnia complaints.

Previous research has shown that healthy young adults with relatively fast reaction times on daytime testing have significantly more nocturnal slow-wave sleep than do age-matched subjects with relatively slow reaction times on such testing. The current study was conducted to examine the relationship between slow-wave sleep and cognitive performance among older adults with and without insomnia complaints. A sample of 32 noncomplaining older (age > or = 60 years) normal sleepers and a like-aged sample of 32 insomniacs, recruited to participate in a larger study, served as subjects. All subjects underwent nocturnal sleep monitoring immediately prior to undergoing a battery of daytime tests that measured simple reaction time, vigilance/signal detection, and complex reaction time. Results from the normal sleepers showed no relationship between daytime cognitive performance measures and a variety of computer-derived nocturnal slow-wave sleep measures. In contrast, insomniac subjects with relatively slow reaction times showed relative deficits in a spectral analytically derived measure of slow-wave power in the 2 to 4 Hz bandwidth. These results suggest that relative performance deficits among some older insomniacs may be related to specific slow-wave sleep deficiencies. However, among older normal sleepers, intersubject differences in performance appear unrelated to slow-wave sleep measures. Additional research is needed to further explore the possible restorative role slow-wave sleep may serve for cognitive functions other than those examined herein.

How many nights are enough? The short-term stability of sleep parameters in elderly insomniacs and normal sleepers.

Temporal stability is an important fundamental quality when measuring sleep parameters, yet it has been infrequently assessed. Generalizability theory was used to estimate the short-term temporal stability of five variables commonly used to characterize insomnia: sleep onset latency, total sleep time, wake after sleep onset, time in bed, and sleep efficiency. Estimates were calculated for 32 elderly primary insomniacs and 32 elderly normal sleepers, both in the lab and at home, using both sleep logs and polysomnography (PSG). A week of recording using either PSG or sleep logs was typically sufficient to achieve adequate stability (defined as G coefficient of at least 0.80) with some notable exceptions: (a) when using log-derived measures with insomniacs, a 3-week average was necessary for wake after sleep onset and (b) more than a 2-week average was necessary for sleep onset latency. Because of the substantial commitment involved in the physiological recording of sleep, alternative forms of aggregation are considered with the intent of improving temporal stability.

Differentiation of human CD8 T cells: implications for in vivo persistence of CD8+ CD28- cytotoxic effector clones.

CD8 T cells contain a distinct subset of CD8+ CD28- cells. These cells are not present at birth and their frequency increases with age. They frequently contain expanded clones using various TCRalphabeta receptors and these clones can represent >50% of all CD8 cells, specially in old subjects or patients with chronic viral infections such as HIV-1. Herein, it is shown that a large fraction of CD8+ CD28- cells expresses intracellular perforin by three-color flow cytometry, in particular when this subset is expanded. Together with their known ability to exert potent re-directed cytotoxicity, this indicates that CD8+ CD28- T cells comprise cytotoxic effector cells. With BrdU labeling, we show that CD8+ CD28- cells derive from CD8+ CD28+ precursors in vitro. In addition, sorted CD8+ CD28+ cells gave rise to a population of CD8+ CD28- cells after allo-stimulation. Moreover, ex vivo CD8+ CD28+ cells contain the majority of CD8 blasts, supporting the notion that they contain the proliferative precursors of CD8+ CD28- cells. CD95 (Fas) expression was lower in CD8+ CD28- cells, and this subset was less prone to spontaneous apoptosis in ex vivo samples and more resistant to activation-induced cell death induced by a superantigen in vitro. Thus, the persistence of expanded clones in vivo in the CD8+ CD28- subset may be explained by antigen-driven differentiation from CD8+ CD28+ memory precursors, with relative resistance to apoptosis as the clones become perforin(+) effector cells.

EBV gene expression not altered in rheumatoid synovia despite the presence of EBV antigen-specific T cell clones.

T cells infiltrating the rheumatoid arthritis (RA) joint are oligoclonal, implicating an Ag-driven process, but the putative joint-specific Ags remain elusive. Here we examine expression of selected EBV genes in RA synovia and find no abnormal expression in RA. DNA of CMV and EBV was detectable by PCR in the synovial tissue of RA. RNA of several latent and lytic EBV genes was also detectable. However, there were no differences in EBV gene expression in synovial tissues or peripheral blood when comparing RA with osteoarthritis, Gulf War syndrome, and other disease controls. RA synovia with highly expanded CD8 T cell clones reactive with defined EBV peptide Ags presented by HLA class I alleles lacked evidence of abnormal mRNA expression for the relevant EBV Ag (BZLF1) or lacked amplifiable mRNA (BMLF1). Thus, local production of EBV Ags in synovial tissues may not be the cause of the accumulation of T cell clones specific for these Ags. Instead, APCs loaded with processed EBV peptides may migrate to the synovium. Alternatively, EBV-specific T cells clones may be generated in other tissues and then migrate to synovia, perhaps due to cross-reactive joint-specific Ags or because of expression of homing receptors.

The significance and management of persistent primary insomnia: the past, present and future of behavioral insomnia therapies.

Persistent primary insomnia (PPI) is a prevalent and potentially serious condition that compromises the functioning, health status, and quality of lives of millions of individuals around the world. This condition is typically perpetuated by a host of psychological and behavioral mechanisms that often require behavioral interventions. Nonetheless, all too commonly, practitioners underestimate the seriousness of this condition or rely too heavily on symptom focused sedative hypnotic therapy for its treatment. Herein we briefly review the epidemiology of PPI and consider the inadequacies of sedative hypnotics for treating this disorder. Subsequently, we provide rationale for the use of behavioral interventions with this condition and we describe the gradual evolution of the currently available behavioral insomnia treatments and consider promising recent developments such as the emergence of cognitive-behavioral and specially tailored, patient-specific approaches. In closing, we consider the potential usefulness of a combined pharmacological/behavioral intervention for PPI and present a number of important research questions to address in future studies of the behavioral insomnia therapies.

Sleep in peri-menopausal and post-menopausal women.

Despite the fact that a large number of women report sleep disturbances associated with peri-menopausal and post-menopausal periods, there is a surprising lack of literature related to this issue. In fact, there has not been enough work in this area to even definitively establish whether there is a sleep disorder that is specifically related to these life-stage changes. Herein we review the available literature which suggests that insomnia may be directly linked to the changes that occur during the peri/post-menopausal periods. This insomnia appears to be due to night sweats caused by the hormonal changes which occur and which lead to an increase in arousals. Persistence of insomnia symptoms after adequate hormone replacement therapy may indicate that behavioral conditioning of the insomnia initially triggered by the night sweats may have occurred. Alternatively, such an insomnia in a peri/post-menopausal woman could be due to unresolved grief related to going through menopause or could reflect an independent sleep disorder, such as periodic movements of sleep, sleep apnea, depression, anxiety, etc. Whereas menopausal changes do not directly lead to an increase in sleep apnea they seemingly contribute to an increased risk for this disorder. In view of these considerations, we provide guidelines for the proper diagnosis and treatment of peri/post-menopausal women with sleep complaints.